Dear Dr. B: I read your column on Steve Jobs and pancreatic cancer. I am puzzled. You say that most people with pancreatic cancer survive only few months after the diagnosis. So how did Jobs, who was diagnosed in the fall of 2003 – and who revealed it publicly in 2004 – manage to survive for eight years? Is it because he could afford to buy good health care?
Answer: That is what it looks like. But the real story is different. Jobs had a rare form of pancreatic cancer, known as neuroendocrine cancer, which grows more slowly and is easier to treat. It is not unusual for patients to survive several years with this type of cancer.
Most common cancer of the pancreas is adenocarcinoma.. My sister had adenocarcinoma. So did Nobel Prize winner immunologist Ralph Steinman, actor Patrick Swayze and football great Gene Upshaw. They all died within a few months of diagnosis. Jobs, with his vast fortune, and Steinman, with his use of experimental immunological treatments, could not forestall indefinitely the dismal outcome of the disease. In the end, both kinds of pancreatic cancers are incurable.
What is the difference between adenocarcinomas and neuroendocrine (NE) tumours?
The pancreas has two distinct kinds of tissue, hence two very different types of cancer. About 95 per cent of pancreatic cancers are adenocarcinomas arising from exocrine glands of the pancreas. These glands produce enzymes to digest fat in our diet.
Scattered in that larger organ are thousands of tiny islands. These are islands of endocrine tissue which makes hormones like insulin that are secreted into the blood. Tumours in these cells are known as islet cells tumours or NE tumours. Jobs had NE cancer.
Approximately half of NE tumours are functioning and half are nonfunctioning. That means patients who have functioning tumours exhibit characteristic syndromes caused by the uncontrolled secretion of insulin, gastrin and other hormones. Consequently, functioning tumours are typically diagnosed when they are smaller than nonfunctioning tumours.
Unfortunately, most patients who have NE carcinomas have locally advanced or metastatic disease. Treatment is directed towards the metastatic disease of the liver. Surgery, chemotherapy, radiotherapy and immunotherapy have been tried. None of them are curative. But palliation and prolongation of life can be gained by few years.
Patients who have locally advanced disease have a median survival of about five years. One form of treatment that is not recommended for most pancreatic cancer is a liver transplant. There is speculation that the liver transplant Jobs received in 2009 had been necessary because the cancer had spread to his liver. In Jobs’ case, did liver transplant prolong his life?
Medical research suggests that patients should be considered for liver transplant if all or most (more than 90 per cent) of NE liver metastases can be resected. Liver resection is safe (operative mortality less than six per cent) and effectively palliates pain and hormonal symptoms in most patients.
Liver transplant may prolong survival but it is not curative because the disease recurs in most patients despite apparent complete resection. Patients who receive liver transplants must take immunosuppressant drugs for the rest of their lives to limit their risk for rejection. But while these drugs serve their purpose, a compromised immune system can leave patients vulnerable to other diseases. Liver transplantation must therefore be considered with great caution.
Steve Jobs was a controversial and complex man when he was alive. After his death, he continues to create speculation and controversy. May his soul rest in peace!
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